Systems and methods for placing materials into bone

ABSTRACT

Systems and methods for delivering material into bone deploy a cannula through soft tissue to establish a subcutaneous path into bone. A material is introduced into bone through the cannula. The systems and methods advance a tamping instrument through the cannula to urge material residing in the cannula into bone. The introducing step delivers material at a pressure no greater than about 360 psi.

FIELD OF THE INVENTION

[0001] The invention generally relates to the treatment of boneconditions in humans and other animals.

BACKGROUND OF THE INVENTION

[0002] Injection devices similar to a household caulking gun are used toinject bone cement into bone. A typical bone cement injection device hasa pistol-shaped body, which supports a cartridge containing bone cement.A trigger actuates a spring-loaded ram, which forces a volume of bonecement in a viscous condition through a suitable nozzle and into theinterior of a bone targeted for treatment. According to the teachings ofU.S. Pat. Nos. 4,969,888 and 5,108,404, a cavity can be first formed bycompacting cancellous bone inside the bone, into which the bone cementis injected. Conventional cement injection devices provide noopportunity to override the spring action and quickly terminate the flowof cement, should the cavity fill before the spring-actuated load cycleis completed. Furthermore, once the spring-actuated mechanism istriggered, conventional cement injection devices do not permit theinjection volume or inject rate to be adjusted or controlled in realtime, in reaction to cancellous bone volume and density conditionsencountered inside bone.

[0003] In a clinical procedure called vertebroplasty, bone cement isinjected at high pressure (typically, about 700 psi) into the interiorof a vertebral body, without the prior formation of a cavity. Becausehigh pressure is used, there is little opportunity to quickly andaccurately adjust cement flow in reaction to bone volume and densityconditions encountered. Momentum generated by high pressure-inducedcement flow continues to propel cement into the targeted bone site evenafter termination of the high pressure.

[0004] As a result of the relatively high pressure that conventionalprocedures rely upon, coupled with the effective lack of a shortresponse time, the targeted bone interior can suddenly overfill. Excessfilling material can be forced outside the bone interior, and intoadjoining tissue regions, where the presence of filling material is notrequired or desired.

[0005] For these and other reasons, there is a need for new systems andmethods for placing material into bones, with greater rate and volumecontrol, a faster response time, and without requiring the use of highpressure.

SUMMARY OF THE INVENTION

[0006] The invention provides instruments, systems, and methods, which,in use, enable greater control over the placement of materials intobone.

[0007] One aspect of the invention provides an instrument for tampingmaterial into bone through a subcutaneous path. The instrument comprisesa body having a length and a terminus. The body includes markingslocated along the length at increments from the terminus. The markingsallow the physician to gauge the position of the instrument in thesubcutaneous path, as material is being tamped into bone. In particular,the markers allow the physician to tell at a glance the location of theterminus, in terms of how far beyond or short of the end of thesubcutaneous path it is.

[0008] In one embodiment, the instrument is used by deploying a cannulato establish a subcutaneous path into bone. A material is introducedinto bone through the cannula. The terminus of the instrument isadvanced through the cannula to urge material residing in the cannulainto bone.

[0009] Another aspect of the invention provides an apparatus forintroducing material into bone through a subcutaneous cannula. Theapparatus includes a delivery device to convey the material at a lowdelivery pressure. As used herein, a “low delivery pressure” isequivalent to the pressure at which liquid is expressed from 1 ccsyringe by the application of moderate force to the syringe piston,which amounts to a pressure that is no greater than about 360 psi.

[0010] According to this aspect of the invention, the apparatus alsoincludes a nozzle instrument capable of advancement through thesubcutaneous cannula into bone. The nozzle comprises a proximal fittingto couple the nozzle instrument to the delivery device. The nozzlefurther comprises a nozzle terminus through which the material conveyedby the delivery device enters bone at the delivery pressure.

[0011] In one embodiment, the delivery device comprises a syringe.

[0012] In one embodiment, the apparatus further includes a tampinginstrument, which is capable of advancement through the subcutaneouscannula. The tamping instrument has a tamping terminus which, during theadvancement, urges material residing in the subcutaneous cannula intobone.

[0013] In one embodiment, the tamping instrument includes markings tovisually gauge the advancement of the tamping terminus through thesubcutaneous cannula.

[0014] In one embodiment, the apparatus is used by deploying a cannulato establish a subcutaneous path into bone. The delivery device isactuated to convey material at the delivery pressure through the nozzleterminus into bone.

[0015] Another aspect of the invention provides a tool for deploymentinto bone. The tool comprises a catheter tube having a distal region andan expandable structure carried by the distal region for compactingcancellous bone. The tool also includes an introducer sleeve slidablycarried by the catheter tube for movement between a retracted positionspaced from the expandable structure and an advanced position overlyingthe expandable structure. The introducer sleeve includes a tubular mainbody dimensioned to compress the expandable structure when theintroducer sleeve is in the advanced position. A collar extends beyondthe distal region of the catheter tube when the introducer sleeve is inthe advanced position. The collar is dimensioned larger than the tubularmain body to releasably engage an end of a cannula. Thus, the introducersleeve both sizes and aligns the expandable structure for passage intothe cannula through the end of the cannula.

[0016] Another aspect of the invention provides apparatus forintroducing material into bone through a subcutaneous cannula. Theapparatus includes a delivery device to convey the material at a lowdelivery pressure, i.e., a pressure no greater than about 360 psi. Theapparatus also includes a nozzle instrument capable of advancementthrough the subcutaneous cannula into bone and comprising a proximalfitting to couple the nozzle instrument to the delivery device. Thenozzle also includes a nozzle bore, through which the material conveyedby the delivery device enters bone at the delivery pressure. Theapparatus further includes a stylet capable of advancement into thenozzle bore through the proximal fitting to close the nozzle bore and,with the nozzle instrument. Together, the nozzle and the stylet form atamping instrument capable of advancement through the subcutaneouscannula to urge residual material from the subcutaneous cannula.

[0017] Another aspect of the invention provides a method for deliveringmaterial into bone. The method deploys a cannula through soft tissue toestablish a subcutaneous path into bone. The method introduces amaterial into bone through the cannula. The method advances a tampinginstrument through the cannula to urge material residing in the cannulainto bone.

[0018] In one embodiment, the method delivers material at a low deliverypressure, i.e., a pressure no greater than about 360 psi.

[0019] In one embodiment, the introducing step uses a manual syringe.

[0020] The material can comprise medication or a material that sets to ahardened condition e.g., bone cement, or autograft tissue, or allografttissue, or synthetic bone substitute, or combinations thereof.

[0021] In one embodiment, the method further includes the step ofdeploying a cavity forming instrument through the cannula to compresscancellous bone and form a cavity. In this embodiment, the introducingand advancing steps convey material into the cavity.

[0022] Features and advantages of the inventions are set forth in thefollowing Description and Drawings, as well as in the appended Claims.

BRIEF DESCRIPTION OF THE DRAWINGS

[0023]FIG. 1 is a plane view of a kit housing a system of functionalinstruments, which, in use, gain subcutaneous access to the inside of abone to compact cancellous bone and form a cavity for therapeuticpurposes;

[0024]FIG. 2 is an exploded perspective view of the kit shown in FIG. 1;

[0025]FIG. 3 is a perspective view of the subcutaneous access instrumentgroup that forms a part of the system shown in FIG. 1;

[0026]FIG. 4A is a perspective view of the cavity forming instrumentthat forms a part of the system shown in FIG. 1;

[0027]FIG. 4B is a section view of the catheter tube of the cavityforming instrument, taken generally along line 4B-4B in FIG. 1;

[0028]FIG. 4C is an end view of an alternative embodiment of the cavityforming instrument shown in FIG. 4A, having a prebent stylet;

[0029]FIG. 5 is a perspective view of the material introducinginstrument group that forms a part of the system shown in FIG. 1;

[0030]FIGS. 6 and 7 are, respectively, top and side views of a humanvertebral body;

[0031]FIG. 8 is a top view of a vertebral body during insertion of aspinal needle instrument to begin a bone access procedure;

[0032] FIGS. 9 to 11 are top views showing subsequent steps, afterinsertion of the spinal needle instrument shown in FIG. 8, of insertinga guide pin instrument into the vertebral body;

[0033]FIG. 12 is a perspective view showing a subsequent step, afterinsertion of the guide pin instrument shown in FIGS. 9 to 11, whichdeploys an obturator instrument deployed over the guide pin instrumentwith aid of a handle;

[0034]FIG. 13 is a top view of the vertebral body, with the obturatorinstrument shown in FIG. 12 deployed;

[0035]FIG. 14 is a perspective view showing a subsequent step, afterinsertion of the obturator instrument shown in FIG. 12, which uses thehandle shown in FIG. 12 to aid in the deployment of a cannula instrumentover the obturator instrument;

[0036]FIG. 15 is a top view of the vertebral body, with the cannulainstrument shown in FIG. 14 deployed;

[0037]FIG. 16 is a perspective view showing a subsequent step, afterinsertion of the cannula instrument shown in FIG. 14, which removes theobturator instrument from the cannula instrument, to leave the cannulainstrument and guide pin instrument in place;

[0038]FIG. 17 is a top view of the vertebral body, after the obturatorremoval step shown in FIG. 16, leaving the cannula instrument and guidepin instrument in place;

[0039]FIG. 18 is a perspective view showing a subsequent step, afterremoval of the obturator instrument shown in FIG. 16, which uses thehandle shown in FIG. 14 to aid in the deployment of a drill bitinstrument through the cannula instrument along the guide pininstrument;

[0040]FIG. 19 is a top view of the vertebral body, as the drill bitinstrument shown in FIG. 18 is deployed with aid of the handle to open apassage into the interior volume of the vertebral body;

[0041]FIG. 20 is a perspective view showing a subsequent step, afterremoval of the drill bit instrument and guide pin instrument shown inFIG. 18, of deploying the cavity forming instrument into the vertebralbody;

[0042]FIG. 21 is a top view of the vertebral body, as the expandablestructure carried by the cavity forming instrument shown in FIG. 20 isdeployed into the interior volume of the vertebral body;

[0043]FIG. 22 is a top view of the vertebral body, as the expandablestructure shown in a collapsed condition in FIG. 21 is expanded tocompact cancellous bone and form a cavity;

[0044]FIG. 23 is a top view of the vertebral body, after removal of theexpandable structure, showing the cavity formed by compacting cancellousbone;

[0045]FIG. 24 is a perspective view of the syringe of the materialintroducing instrument group, shown in FIG. 5, being filled with amaterial selected for introduction into the cavity shown in FIG. 23;

[0046]FIG. 25 is a perspective view of the syringe shown in FIG. 24being joined to a nozzle, which also forms a part of the materialintroducing instrument group shown in FIG. 5;

[0047]FIG. 26 is a perspective view showing the syringe and attachednozzle shown in FIG. 25 being deployed through the cannula instrument inpreparation of introducing material into the cavity;

[0048]FIGS. 27 and 28 are perspective and top views, respectively,showing the syringe and attached nozzle shown in FIG. 26 in use toinject material into the cannula instrument for passage into the cavity;

[0049]FIG. 29 is a top view of the vertebral body after a measuredvolume of material has been injected and the syringe and attached nozzlewithdrawn from the cannula instrument;

[0050]FIG. 30 is a top view showing the deployment of a tampinginstrument, which forms a part of the material introducing instrumentgroup shown in FIG. 5, being deployed in the cannula instrument;

[0051]FIG. 31 is a top view showing advancement of the tampinginstrument in the cannula instrument to displace and distribute materialfrom the cannula instrument into the cavity;

[0052]FIG. 32 is a top view of the vertebral body after removal of thetamping instrument and cannula instrument, showing the cavity, nowfilled with the material;

[0053]FIG. 33 is a perspective view of a reduced diameter cannulainstrument and associated reduced diameter material introducinginstruments, which embody features of the invention;

[0054]FIG. 34 is a perspective view of a cavity forming instrumenthaving an expandable cavity forming structure, which, in use, isdeployed using the reduced diameter cannula instrument shown in FIG. 33,the cavity forming instrument having a sliding introducer sleeve shownin its rearward position;

[0055]FIG. 35 is a perspective view of the cavity forming instrumentshown in FIG. 34, with the introducer sleeve moved forward to overlieand compress the expandable cavity forming structure;

[0056]FIG. 36 is a perspective view of the cavity forming structureshown in FIG. 35, with the introducer sleeve (shown partially insection) coupled to the proximal end of the cannula instrument, to guidethe expandable structure compressed within the sleeve into the reduceddiameter cannula instrument without damage; and

[0057]FIG. 37 is a perspective view of the cavity forming structureshown in FIG. 36, after the expandable structure has been guided by theintroducer sleeve into the cannula instrument and is being advancedthrough the cannula instrument for deployment in bone.

[0058] The invention may be embodied in several forms without departingfrom its spirit or essential characteristics. The scope of the inventionis defined in the appended claims, rather than in the specificdescription preceding them. All embodiments that fall within the meaningand range of equivalency of the claims are therefore intended to beembraced by the claims.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0059]FIGS. 1 and 2 show a system 10 of functional instruments. In use,certain instruments of the system 10 are deployed in a purposeful mannerto penetrate tissue and gain subcutaneous access to the inside of abone. Inside bone, other instruments of the system 10 are deployed toform a cavity in cancellous bone, into which a material is placed fortherapeutic purposes.

[0060] In the illustrated embodiment, the system 10 is arranged as aprepackage kit 12 in three functional instrument groups 14, 16, and 18.The first group 14 (which FIG. 3 shows outside the kit 12) comprisesinstruments whose purpose is to gain subcutaneous access to a boneinterior. The second group 16 (which FIG. 4 shows outside the kit 12)comprises an instrument whose function is to create a cavity incancellous bone. The third group 18 (which FIG. 5 shows outside the kit12) comprises instruments whose function is to introduce a material intothe cavity.

[0061] The kit 12 can take various forms. In the illustrated embodiment,the kit 12 comprises a sterile, wrapped assembly.

[0062] Further details of each functional instrument group 14, 16, and18 and the kit 12 follow.

[0063] I. The Subcutaneous Access Instrument Group

[0064] The number and type of instruments in the group 14 can vary. FIG.3 shows five representative instruments, each having a different sizeand function.

[0065] A. The Spinal Needle and Guide Pin

[0066] As FIG. 3 shows, one instrument comprises a conventional spinalneedle assembly 20 and a guide pin instrument 26.

[0067] In use, the spinal needle assembly 20 establishes the initialsubcutaneous path leading to the targeted treatment site. The guide pininstrument 26 is deployed through this path, followed by progressivelylarger instruments, as will be described later.

[0068] The spinal needle assembly 20 comprises a stylet 22, which isslidably deployed within a stylus 24. The stylus 24 typically has, forexample, about an eleven gauge diameter. Other gauge diameters can beused, according to the gauge of the guide pin instrument 26 used.

[0069] In use, the guide pin instrument 26 is deployed through thesubcutaneous path established by the spinal needle assembly 20, byexchange with the needle stylet 22. The guide pin instrument 26 servesto guide the establishment of the main operative pathway to the targetedtreatment site.

[0070] The remaining instruments 28, 30, and 32 in the group 14 sharesome common features, although they are intended, in use, to performdifferent functions. These instruments 28, 30, and 32 are each made of arigid, surgical grade plastic or metal material. These instruments 28,30, and 32 each comprises an elongated, cylindrical body having aproximal end 34 and a distal end 36.

[0071] B. The Obturator Instrument

[0072] The instrument 28 functions as an obturator. Its distal end 36 istapered to present a penetrating surface 38. In use, the surface 38 isintended to penetrate soft tissue in response to pushing or twistingforces applied by the physician at the proximal end 34.

[0073] The proximal end 34 of the obturator instrument 28 presents aflanged surface 40, which tapers from a larger outer diameter to asmaller outer diameter in the direction of the proximal end 34. Theflanged surface 40 includes an array of circumferentially spaced teeth42.

[0074] An interior lumen 44 extends through the obturator instrument 28from the distal end 36 to the proximal end 34. The interior lumen 44 issized to accommodate the guide pin instrument 26, as will be describedin greater detail later.

[0075] C. The Cannula Instrument

[0076] The instrument 30 functions as a cannula or guide sheath. Thecannula instrument 30 is somewhat larger in diameter than and not aslong as the obturator instrument 28. The cannula instrument 30 includesan interior lumen 46 that extends from its distal end 36 to its proximalend 34. The interior lumen 46 is sized to accept the obturatorinstrument 28. The size of the interior lumen 46 permits a physician toslide and rotate the cannula instrument 30 relative to the obturatorinstrument 28, and vice versa, as will be described in greater detaillater.

[0077] The distal end 36 of the cannula instrument 30 presents an endsurface 48. In use, the end surface 48 of the cannula instrument 30 isintended to penetrate soft tissue surrounding the obturator instrument28 in response to pushing or twisting forces applied at the proximal end34.

[0078] The proximal end 34 carries an enlarged fitting 50. The fitting50 tapers from a larger diameter to a smaller diameter in the directionof the proximal end 34. Like the tapered flange 40 on the obturatorinstrument 28, the tapered fitting 50 has an array of circumferentiallyspaced teeth 52. The tapered fitting 50 of the cannula instrument 30possesses a larger maximum outer diameter than the maximum outerdiameter of the tapered flange 40 of the obturator instrument 28.

[0079] The cannula instrument 30 includes measured markings 118 alongits length(see FIG. 3). The measured markings 118 gauge the depth ofinsertion. The markings 118 can be placed, for example, at onecentimeter intervals. As FIG. 3 shows, the markings 118 can beconsecutively numbered, beginning at the distal end 36, so that thephysician can ascertain the insertion depth at a glance.

[0080] D. The Drill Bit Instrument

[0081] The instrument 32 functions as a drill bit. The drill bitinstrument 32 has generally the same physical dimensions as theobturator instrument 28. Like the obturator instrument 28, the drill bitinstrument 32 is intended, in use, to fit for sliding and rotationalmovement within the interior lumen 46 of the cannula instrument 30.

[0082] The distal end 36 of the drill bit instrument 32 includesmachined cutting edges 54. In use, the cutting edges 54 are intended topenetrate hard tissue in response to rotation and longitudinal loadforces applied at the proximal end 34 of the drill bit instrument 32.

[0083] The proximal end 34 presents a tapered flange 56, which issubstantially identical to the flange 40 on the obturator instrument 28.Like the obturator instrument 28, the tapered flange 56 changes from alarger diameter to a smaller diameter in the direction of the proximalend 34. The tapered flange 56 of the drill bit instrument 32 alsoincludes an array of circumferentially spaced teeth 58. The form andorientation of the teeth 58 on the drill bit instrument 32 correspond tothe form and orientation of the teeth 42 on the obturator instrument 28.

[0084] E. The Handle

[0085] The group includes a handle 60. The handle 60 engages thefunctional instruments 28, 30, and 32 in a removable, slip fit fashionto aid a physician in manipulating the instruments during use.

[0086] The handle 60 is made from a molded or cast rigid plastic ormetal material. The handle 60 is shaped to be comfortably and securelygrasped by a normal human hand. The shape and size to accommodate thisfunction can, of course, vary. In the illustrated embodiment, the handle60 is elongated along a main axis to fit comfortably across the palm ofthe hand.

[0087] The handle 60 includes a center post 62, which is integrallymolded to the handle 60 about its geometric center. The center post 62extends downward to give the handle 60 a general T-shape.

[0088] The handle 60 includes two interior cavities or sockets 64 and 66in the center post 62. The sockets guide the attachment between thehandle 60 and the instruments 28, 30, and 32. The first and secondsockets 64 and 66 are sized to present unique attachment sites fordifferent functional instruments.

[0089] The first socket 64 includes an array of circumferentially spacedgrooves 68, which, in form and orientation, match the teeth 42 and 58 atthe proximal ends 34 of the obturator instrument 28 and the drill bitinstrument 32. The first socket 64 accepts the tapered flange 40 or 56of either the obturator instrument 28 or the drill bit instrument 32.The teeth 42 and 58 of either tapered flange 40 or 56 mesh in a slip-fitwith the grooves 68 of the first socket 64. The running slip-fit allowslongitudinal force to be applied to either instrument 28 or 32 throughthe handle 60. The running slip-fit also prevents relative rotationbetween either instrument 28 or 32 and the first socket 64, therebypermitting torsional or twisting forces to be applied to eitherinstrument 28 or 32 by the handle 60, with an increased mechanicaladvantage.

[0090] The second socket 66 is larger than the first socket 64 and issized to accept the larger tapered fitting 50 of the cannula instrument30. The second socket 66 includes an array of circumferentially spacedgrooves 70, which, in form and orientation, match the teeth 52 on thetapered fitting 50. The teeth 52 of the tapered fitting 50 mesh in aslip-fit with the grooves 70 of the second socket 66. The runningslip-fit allows both longitudinal and torsional forces to be applied tothe cannula instrument 30 through the handle 60, with increasedmechanical advantage.

[0091] As shown in phantom lines in FIG. 3, a first passage 72 extendsthrough the top of the handle 60, through the center post 62, and intothe first socket 64. The passage 72 is generally aligned with the centerof the first socket 64 and is sized to pass the guide pin instrument 26(see FIG. 12).

[0092] Likewise, as also shown in phantom lines in FIG. 3) a secondpassage 74 extends through the top of the handle 60, through the centerpost 62, and into the second socket 66. The passage 74 is generallyaligned with the center of the second socket 66 and is sized to pass theeither obturator instrument 28 or the drill bit instrument 32 (see FIG.14).

[0093] Further details of the handle 60 can be found in copending U.S.patent application Ser. No. 09/014,229, filed Jan. 27, 1998, andentitled “A Slip-Fit Handle for Hand-Held Instruments that AccessInterior Body Regions.”

[0094] Further details regarding the use of the handle 60 and theassociated instruments 26, 28, and 30 will be provided later.

[0095] II. The Cavity Forming Instrument

[0096] As FIG. 4A shows, the group 16 includes an instrument 76, whichis deployed through the cannula instrument 30 to a location inside bone(see FIG. 20). When so deployed, the instrument 76 serves to form acavity in cancellous bone.

[0097] The instrument 76 can be constructed in various ways. In theillustrated embodiment, the instrument 76 includes a flexible cathetertube 78 having a proximal end 80 and a distal end 82. The proximal end80 carries a handle grip 84 to facilitate gripping and maneuvering thecatheter tube 78. The materials for the catheter tube 78 are selected tofacilitate its advancement through the cannula instrument 30. Thecatheter tube 78 can be constructed, for example, using standardflexible, medical grade plastic materials, like vinyl, nylon,polyethylenes, ionomer, polyurethane, and polyethylene tetraphthalate(PET). The catheter tube 78 can also include more rigid materials toimpart greater stiffness and thereby aid in its manipulation. More rigidmaterials that can be used for this purpose include stainless steel,nickel-titanium alloys (Nitinol™ material), and other metal alloys.

[0098] The distal end 82 of the instrument 76 carries an expandablestructure 86. In the illustrated embodiment, the expandable structure 86is made from a polyurethane or an elastomer (e.g., silicone or nylon)material. The structure 86 has been preformed to possess a desired shapeby exposure to heat and pressure, e.g., through the use of conventionalthermoforming techniques.

[0099] As FIG. 4B shows, the catheter body 78 includes an interior lumen88, which communicates with the interior of the structure 86. A fitting90 on the proximal end 80 of the catheter tube 78 (see FIG. 4B)communicates with the lumen 88. The fitting 90 couples the lumen 88 to asource 92 of fluid, e.g., sterile saline (see FIG. 21), or a radiopaquecontrast medium.

[0100] The fluid is introduced from the source 92 into the structure 86under positive pressure, causing the structure 86 to expand. Duringexpansion inside bone, the material selected for the structure 86preferably resists deformation, so that the expanded shape inside boneessentially corresponds to its expanded shape outside bone, i.e., whenin an open air environment. This allows the physician to select in anopen air environment a structure 86 having an expanded shape desired tomeet the targeted therapeutic result, with the confidence that theexpanded shape inside bone will be similar in important respects. Inaddition to being able to expand its volume while resisting deformationinside bone, the material of the structure 86 preferable withstandsabrasion, tearing, and puncture when in contact with cancellous bone.

[0101] The shape of the structure 86, when expanded inside bone, isselected by the physician, taking into account the morphology andgeometry of the site to be treated. The shape of the cancellous bone tobe compressed, and the local structures that could be harmed if bonewere moved inappropriately, are generally understood by medicalprofessionals using textbooks of human skeletal anatomy along with theirknowledge of the site and its disease or injury. The physician is alsoable to select the expanded shape inside bone based upon prior analysisof the morphology of the targeted bone using, for example, plain filmx-ray, fluroscopic x-ray, or MRI or CT scanning. The expanded shapeinside bone is selected to optimize the formation of a cavity that,e.g., when filled with a suitable material, provides support across theregion of the bone being treated.

[0102] As one general guideline, in cases where the bone disease causingfracture (or the risk of fracture) is the loss of cancellous bone mass(as in osteoporosis), the selection of the expanded shape of thestructure 86 inside bone should take into account that from 30% to 90%of the cancellous bone volume should be compacted. Another generalguideline is the amount that the targeted fractured bone region has beendisplaced or depressed. The expansion of the structure 86 within thecancellous bone region inside a bone can elevate or push the fracturedcortical wall back to or near its anatomic position occupied beforefracture occurred.

[0103] In the illustrated embodiment (see FIG. 4A), the structure 86possesses a preformed hour-glass or peanut shape. This shape is selectedin contemplation of deploying the structure 86 in a vertebral body, aswill be described in greater detail later.

[0104] To facilitate deployment of the structure 86 through the cannulainstrument 30, the catheter tube 78 includes a second interior lumen 94.The lumen 94 extends from a second fitting 98 on the proximal end 80 ofthe catheter tube 78, through the body of the cannula tube 78, andthrough the interior of the structure 86 to the tip end 172 of thestructure 86. The lumen 94 receives a generally stiff stylet 96, whichcan be made from a molded plastic or stainless steel material. Thestylet 96 is inserted through the fitting 98 into the lumen 94, andincludes a threaded coupling 100 to secure the stylet 96 againstmovement. The presence of the stylet 96 serves to keep the structure 86in the desired distally straightened condition during passage throughthe cannula instrument 30 into the targeted tissue region. Once thestructure 86 is free of the cannula instrument 30 and inside bone, thestylet 96 can be withdrawn (shown by arrow 174 in FIG. 4A). This returnsnormal flexibility to the catheter tube 78 and facilitates manipulationof the structure 86 inside bone. With the stylet 96 withdrawn, the lumen94 can also serve as a pathway for introducing rinsing liquid or toaspirate debris from the bone.

[0105] In the illustrated embodiment, the stylet 96 is biased toward agenerally straight condition. In an alternative embodiment (see FIG.4C), a stylet 102 can have a preformed memory, to normally bend itsdistal region. The memory is overcome to straighten the stylet 102 whenconfined within the cannula instrument 30. However, as the structure 86and distal region of the preformed stylet 102 advance free of thecannula instrument 30, to pass into the targeted region, the preformedmemory bends the distal region of the stylet 102 and thereby shifts themain axis of the expandable structure 86. The prebent stylet 102,positioned within the interior of the structure 86, aids in altering theorientation of the structure 86, bringing it into better anatomicalignment with the targeted region.

[0106] Other types of instruments that can form cavities in cancellousbone and other interior body regions are described in copending U.S.patent application Ser. No. 09/055,805, entitled “Structures and Methodsfor Creating Cavities in Interior Body Regions,” filed Apr. 6, 1998.

[0107] III. The Material Introducing Instrument Group

[0108] The group 18 includes instruments 104, 106, and 108 which serveto convey and compact a selected material inside the cavity formed bythe structure 86. The material in the cavity provides a desiredtherapeutic result, e.g., replacement of tissue mass, or renewedinterior support for the bone, or the delivery of medication, orcombinations thereof. Accordingly, the material to perform this functioncan be selected from among, e.g., a material that sets to a hardenedcondition, including bone cement, autograft tissue, allograft tissue,synthetic bone substitute, as well as a medication, or combinationsthereof.

[0109] In the illustrated embodiment, the group 18 comprises materialinjection instruments 104 and 106 and a material tamping instrument 108,which deliver material at a low delivery pressure, i.e., a pressure nogreater than about 360 psi.

[0110] A. Low Pressure Material Injection Instruments

[0111] In the illustrated embodiment, the material is injected by use ofa conventional syringe 104, to which a specially designed injectionnozzle 106 is coupled. A manual actuated syringe with a push plunger canbe used. Alternatively, a LeVeen Inflation Syringe with threaded plungercan be used, which can be actuated manually or by use of a mechanicalactuator.

[0112] In the illustrated embodiment, the syringe 104 is made from aclear plastic material. The syringe 104 includes a chamber 110, whichreceives the material to be injected. The material is expressed from thechamber 100 by a manually advanced syringe piston 112 (see also FIG.25).

[0113] The injection nozzle 106 connects by a threaded connector 114 tothe end of the syringe 104 9 (see also FIG. 25). In the illustratedembodiment, the nozzle 106 is made from a generally flexible, inertplastic material, such as such as polyethylene or an other suitablepolymer. Alternatively, the nozzle 106 can be made from a generallyrigid plastic or metal material.

[0114] The injection nozzle 106 is sized to be advanced through thecannula instrument 30 (see FIG. 26). The nozzle 106 includes measuredmarkings 116 along its length. The markings 116 can be placed, forexample, at one centimeter intervals, to correspond with the markings118 on the cannula instrument 30, so that the relative position of thenozzle 106 within the cannula instrument 30 can be gauged. The markings118 can, e.g., include a set point 176. Alignment of the set point 176at the proximal end 34 of the cannula instrument 30, indicates that thedistal end of the nozzle 106 is located in an aligned relationship withthe distal end 36 of the cannula instrument 30. In this arrangement, themarkings 118 are consecutively numbered with positive numbers proximallyof the set point 176 and with negative numbers distally of the set point176. The physician is thereby able to tell at a glance the location ofthe distal end of the nozzle 106, in terms of how far beyond or short ofthe distal end 36 of the cannula instrument 30 it is.

[0115] In use, the distal end of the nozzle 106 is located beyond thedistal end 36 of the cannula instrument 30 within the cavity formed inthe targeted tissue region. As FIG. 5 shows, the distal end of thenozzle 106, when made from a plastic material, can carry at least oneradiopaque marker 208, to enable remote visualization of the nozzleposition within the body. The syringe 104 ejects a predetermined volumeof material into the nozzle 106 in a low pressure stream into thecavity. As the material fills the cavity, the nozzle (still ejectingmaterial) is retracted from the cavity and into the cannula instrument30 itself. Further details of this function and result will be providedlater.

[0116] B. The Material Tamping Instrument

[0117] The group 18 also includes a material tamping instrument 108. Thetamping instrument 108 is made from generally rigid, inert plastic ormetal material. The tamping instrument 108 is also sized to be advancedinto the cannula instrument 30 (see FIG. 30). The free end 124 of thetamping instrument 108 is ribbed or contoured to facilitate gripping theinstrument 108 during use.

[0118] The tamping instrument 108 includes measured markings 122 alongits length. The markings 116 can be placed, for example, at onecentimeter intervals, to correspond with the markings 118 on the cannulainstrument 30, so that the relative position of the tamping instrument108 within the cannula instrument 30 can be gauged. Like the nozzle 106,the markings 122 on the tamping instrument 108 includes a set point 178,which indicates when the distal end of the tamping instrument 108 alignswith the distal end 36 of the cannula instrument 30. Also like thenozzle 106, the markings 122 on the tamping instrument 108 areconsecutively numbered with positive numbers proximally of the set point178 and with negative numbers distally of the set point 178. Thephysician is thereby able to tell at a glance the location of the end ofthe tamping instrument 108, in terms of how far beyond or short of thedistal end 36 of the cannula instrument 30 it is. As FIG. 5 also shows,the end of the tamping instrument 108, when made from a plasticmaterial, can carry at least one radiopaque marker 210, so that itsposition can be visualized from outside the body.

[0119] After withdrawal of the nozzle 106 from the cannula instrument30, residual material is left in the cannula instrument 30. The purposeof the tamping instrument 108 is to displace the residual material outthe distal end 36 of the cannula instrument 30 and into the cavity, tothereby fill the cavity without exerting undue pressure within the bone.The tamping instrument 108 thereby serves to clear residual materialfrom the cannula instrument 30, to assure that the desired volume ofmaterial is delivered into the cavity. The removal of residual materialfrom the cannula instrument 30 by the tamping instrument 108 alsoprevents seepage of material into surrounding tissue regions uponremoval of the cannula instrument 30. The tamping instrument 108 alsocompacts the material uniformly within the cavity, again without unduepressure. Further details of these functions and results will bediscussed later.

[0120] IV. The Kit

[0121] As FIGS. 1 and 2 show, in the illustrated embodiment, the kit 12includes an interior tray 126 made, e.g., from die cut cardboard,plastic sheet, or thermo-formed plastic material. The tray 126 includesspaced apart tabs 128, which hold the various instruments in a secureposition during sterilization and storage prior to use.

[0122] When packaged as a sterile assembly, the kit 12 includes an innerwrap 130, which is peripherally sealed by heat or the like, to enclosethe tray 126 from contact with the outside environment. One end of theinner wrap includes a conventional peal-away seal 132, to provide quickaccess to the tray 126 at the instant of use, which preferably occurs ina sterile environment, such as within an operating room.

[0123] When packaged as a sterile assembly, the kit 12 also includes anouter wrap 134, which is also peripherally sealed by heat or the like,to enclosed the inner wrap 130. One end of the outer wrap includes aconventional peal-away seal 136, to provide access to the inner wrap 130and its contents. The outer wrap 134 can be removed from the inner wrapin anticipation of imminent use, without compromising sterility of thecontents of the kit 12.

[0124] As FIG. 2 shows, each inner and outer wrap 130 and 134 includes aperipherally sealed top sheet 138 and bottom sheet 140. In theillustrated embodiment, the top sheet 138 is made of transparent plasticfilm, like polyethylene or MYLAR® material, to allow visualidentification of the contents of the kit 12. The bottom sheet 140 ismade from a material that is permeable to ETO sterilization gas, e.g.,TYVEK® plastic material (available from DuPont).

[0125] In the illustrated embodiment, the tray 126 presents theinstruments groups 14, 16, and 18 in an ordered, organized layout, whichis arranged to aid the physician in carrying out the intended procedure.For example, the layout of the tray 126 can present the instrumentsgroups 14, 16, and 18 in top-to-bottom order, according to sequence ofintended use. For example, in a typical bone access procedure (as willbe demonstrated in greater detail later), the stylet 22 and stylus 24 ofthe spinal needle assembly 20 are deployed first, followed by the guidepin instrument 26, followed by the obturator instrument 28, then thecannula instrument 30, then the drill bit instrument 32, then the cavityforming instrument 76, then the syringe 104 and nozzle 106 instruments,and lastly the tamping instrument 108. Accordingly, the tray 126packages these instruments and components in a top-to-bottom order, withthe spinal needle assembly 20 topmost, the guide pin instrument 26 next,the obturator instrument 28 next, and so on, with the tamping instrument108 lowermost on the tray 126.

[0126] In this layout, the handle 60 is packaged to the side of theaccess instrument group 14. The tray 126 can include written labels (notshown) identifying the components contained in the kit 12.

[0127] The kit 12 also preferably includes in the tray 126 directions144 for using the contents of the kit 12 to carry out a desiredprocedure. An exemplary procedure which the directions 144 can describewill be explained later.

[0128] When packaged as a sterile assembly, the directions 144 can alsoinclude the statement “For Single Patient Use Only” (or comparablelanguage) to affirmatively caution against reuse of the contents of thekit 12 whose performance characteristics and efficacy degrade after asingle use. The spinal needle assembly 20, the cavity forming instrument76, and the material introducing instruments 104, 106, and 108 should,for these reasons, be used but a single time and then discarded. Thedirections 144 also preferably affirmatively instruct againstresterilization of at least these contents of kit 12, and also instructsthe physician to dispose of at least these contents of the kit 12 uponuse in accordance with applicable biological waste procedures.

[0129] The presence of the instrument groups 14, 16, and 18 packaged inthe sterile kit 12 verifies to the physician that the contents aresterile and have not been subjected to prior use. The physician isthereby assured that the instrument groups meet established performanceand sterility specifications.

[0130] It should be appreciated that the various instruments containedin the kit 12 can be packaged into several, smaller functional kits. Forexample, a first kit can package the access instrument group 14, asecond kit can package the cavity forming instrument group 16, and athird kit can package the material introduction instrument group 18.FIGS. 1 and 2 illustrate one of many different possible embodiments.

[0131] V. Illustrative Use of the System

[0132] The following describes use of the instrument groups 14, 16, and18 packaged in the kit 12 in the context of treating bones. This isbecause the instruments of the groups 14, 16, and 18 can beadvantageously used for this purpose. Still, it should be appreciatedthat one or more of the instrument groups, used alone or in associationwith other instruments, can perform other diagnostic or therapeuticfunctions in other interior regions of the body.

[0133] In particular, the instrument groups 14, 16, and 18 willdescribed with regard to the treatment of human vertebra. It should beappreciated, however, their use is not limited to human vertebrae. Theinstrument groups 14, 16, and 18 can be used in association withhand-held instruments in the treatment of diverse human or animal bonetypes.

[0134] A. The Vertebral Body

[0135] As FIGS. 6 and 7 show, a typical vertebra 146 includes avertebral body 148, which extends on the anterior (i.e., front or chest)side of the vertebra 146. The vertebral body 148 has the shape of anoval disk. The vertebral body 148 includes an exterior formed fromcompact cortical bone 150. The cortical bone 150 encloses an interiorvolume of reticulated cancellous, or spongy, bone 152 (also calledmedullary bone or trabecular bone).

[0136] The spinal cord 154 passes through the spinal canal 156 of thevertebra 146. The vertebral arch 158 surrounds the spinal canal 156. Thepedicles 160 of the vertebral arch 158 adjoin the vertebral body 148.The spinous process 162 extends from the posterior of the vertebral arch158, as do the left and right transverse processes 164.

[0137] B. Treatment of a Vertebral Body

[0138] During a typical procedure, a patient lies on an operating table.The patient can lie face down on the table, or on either side, or at anoblique angle, depending upon the physician's preference.

[0139] The physician or surgical assistant removes the outer and innerwraps 130 and 134 of the kit 12, exposing the tray 126 for use. Thephysician acquires the spinal needle assembly 20 from the tray 126. AsFIG. 8 shows, the physician introduces the spinal needle assembly 20into soft tissue ST in the patient's back. Under radiologic or CTmonitoring, the physician advances the spinal needle assembly 20 throughsoft tissue down to and into the targeted vertebra 146. The physicianwill typically administer a local anesthetic, for example, lidocaine,through assembly 20. In some cases, the physician may prefer other formsof anesthesia.

[0140] The physician directs the spinal needle assembly 20 to penetratethe cortical bone 150 and the cancellous bone 152 of the targetedvertebral body 148. Preferably the depth of penetration is about 60% to95% of the vertebral body 148.

[0141]FIG. 8 shows gaining access to cancellous bone through the side ofthe vertebral body 148, which is called postero-lateral access. However,access may be indicated through a pedicle 160, which is calledtranspedicular access. The type of access is based upon the objectivesof the treatment or for other reasons, based upon the preference of thephysician.

[0142] As FIG. 9 shows, after positioning the spinal needle assembly 20in cancellous bone 152, the physician holds the stylus 24 and withdrawsthe stylet 22. The physician acquires the guide pin instrument 26 fromthe tray 126. As FIG. 10 shows, while still holding the stylus 24, thephysician slides the guide pin instrument 26 through the stylus 24 andinto the cancellous bone 152. The physician now removes the stylus 24(see FIG. 11), leaving the guide pin instrument 26 deployed within thecancellous bone 152.

[0143] The physician next acquires the obturator instrument 28 and thehandle 60 from the tray 126. The physician slides the obturatorinstrument 28 over the guide pin instrument 26, distal end first. Thephysician slides the guide pin instrument 26 through the first passage72 and the first socket 64 of the handle 60. As FIG. 12 shows, thephysician slides the handle 60 along the guide pin instrument 26 towardthe tapered flange 40 of the obturator instrument 28, until achieving arunning slip-fit between the first socket 64 and the tapered flange 40,in the manner previously described. The obturator instrument 28 is nowready for use.

[0144] As FIG. 12 shows, the physician makes a small incision I in thepatient's back. The physician twists the handle 60 while applyinglongitudinal force to the handle 60. In response, the surface 38 of theobturator instrument 28 rotates and penetrates soft tissue ST throughthe incision I. The physician may also gently tap the handle 60, orotherwise apply appropriate additional longitudinal force to the handle60, to advance the obturator instrument 28 through the soft tissue alongthe guide pin instrument 26 down to the entry site (see FIG. 13). Thephysician can also tap the handle 60 with an appropriate striking toolto advance the surface 30 of the obturator instrument 28 into the sideof the vertebral body 148 to secure its position (as FIG. 13 shows).

[0145] The physician next slides the handle 60 along the guide pininstrument 26 away from the obturator instrument 28 to disengage thetapered flange 40 from the first socket 64. The physician then proceedsto slide the handle 60 completely off the guide pin instrument 26.

[0146] The physician acquires the cannula instrument 30 from the tray126. As FIG. 14 shows, the physician slides the cannula instrument 30over the guide pin instrument 26, distal end first, and, further, overthe obturator instrument 28, until contact between the end surface 48and soft tissue tissue ST. The physician now slides the guide pininstrument 26 and obturator instrument 26 through the second passage 74and second socket 66 of the handle 60. The physician slides the handle60 toward the tapered fitting 50 of the cannula instrument 30 until arunning slip-fit occurs between the second socket 66 and the taperedfitting 50, as previously described. The cannula instrument 30 is nowready for use.

[0147] As FIG. 14 shows, the physician applies appropriate twisting andlongitudinal forces to the handle 60, to rotate and advance the cannulainstrument 30 through soft tissue ST along the obturator instrument 28.As FIG. 15 shows, when the end surface 48 of the cannula instrument 30contacts cortical bone, the physician can appropriately tap the handle60 with a striking tool to advance the end surface into the side of thevertebral body 148 to secure its position.

[0148] As FIG. 16 shows, the physician now withdraws the obturatorinstrument 28, sliding it off the guide pin instrument 26. This leavesthe guide pin instrument 26 and the cannula instrument 30 in place, asFIG. 17 shows. The physician next slides the handle 60 along the guidepin instrument 26 away from the cannula instrument 30 to disengage thetapered fitting 50 from the second socket 66. The physician then slidesthe handle 60 completely off the guide pin instrument 26.

[0149] The physician now acquires the drill bit instrument 32 from thetray 126. As FIG. 18 shows, the physician slides the drill bitinstrument 32 over the guide pin instrument 26, distal end first,through the cannula instrument 30 until contact between the machinedsurface 54 and bone tissue occurs. As FIG. 18 also shows, the physiciannext leads the guide pin instrument 26 through the first passage 72 andfirst socket 64 of the handle 60. The physician slides the handle 60along the guide pin instrument 26 toward the tapered flange 56 of thedrill bit instrument 32, until a running slip-fit occurs between thefirst socket 64 and the tapered flange 56, as previously described. Thedrill bit instrument 32 is now ready for use.

[0150] As shown by FIG. 18, guided by X-ray (or another externalvisualizing system), the physician applies appropriate twisting andlongitudinal forces to the handle 60, to rotate and advance the cuttingedge 54 of the drill bit instrument 32 to open a passage 166 (see FIG.19) through the bone tissue and completely into the cancellous bone 152.The drilled passage 166 preferable extends no more than 95% across thevertebral body 148.

[0151] The physician now slides the handle 60 along the guide pininstrument 26 away from the drill bit instrument 32 to disengage thetapered flange 56 from the first socket 64. The physician, further,slides the handle 60 completely off the guide pin instrument 26.

[0152] The physician can now remove the drill bit instrument 32 and theguide pin instrument 26, leaving only the cannula instrument 30 inplace. The passage 166 made by the drill bit instrument 32 remains.Subcutaneous access to the cancellous bone 152 has been accomplished.

[0153] The physician can now acquire the cavity forming instrument fromthe tray 126. As FIG. 20 shows, the physician can advance the expandablestructure 86 through the cannula instrument 30 and passage 166 into theinterior volume of the vertebral body 148, as FIG. 21 also shows. Thestructure 86 is in its normally collapsed and not expanded conditionduring deployment. The stylet 96 or 102 is inserted in the lumen 94 ofthe catheter tube 78 to provide added stiffness to the structure 86while being passed through the cannula instrument 30.

[0154] As shown in phantom lines in FIG. 20, the physician can, ifdesired, reconnect the handle 60 to the cannula instrument 30, to helpstabilize the cannula instrument 30 while deploying the structure 86.The second passage 74 of the handle accommodates the catheter tube 78and the structure 86, when collapsed.

[0155] As FIG. 21 shows, the structure 86 is oriented in the desired wayin the passage 166. As before explained, the bent stylet 102 can aid inthis task. Before, during, or after the orientation process, the stylet96 or 102 can be withdrawn (as FIG. 21 shows), to open the lumen 94 foruse to pass a rinsing liquid or negative aspiration pressure.

[0156] Sterile liquid is conveyed under pressure from the source 92through the lumen 88 into the structure 86. As FIG. 22 shows, thestructure 86 expands inside bone. Expansion of the structure 86compresses cancellous bone 152 in the vertebral body 148.

[0157] The compression forms an interior cavity 168 in the cancellousbone 152. As FIG. 23 shows, subsequent collapse and removal of thestructure 86 leaves the cavity 168 in a condition to receive a fillingmaterial.

[0158] The compaction of cancellous bone 152 can also exert interiorforce upon cortical bone, making it possible to elevate or push brokenand compressed bone back to or near its original prefracture, or otherdesired, condition.

[0159] Upon formation of the cavity 168, the physician acquires thesyringe 104 and injection nozzle 106 from the kit 12. As FIG. 24 shows,the physician fills the syringe chamber 110 with the desired volume offilling material 170. As FIG. 25 shows, the physician attaches thenozzle 106 to the filled syringe 104. As FIG. 26 shows, the physicianinserts the nozzle 106 a selected distance beyond the distal end 36 ofthe cannula instrument 30 and into the cavity, guided by the markings116.

[0160] As shown in phantom lines in FIG. 26, the handle 60 can remainattached to the cannula instrument 30 to provide stability, as thesecond passage 74 of the handle accommodates the nozzle 106.

[0161] As FIG. 27 shows, the physician manually advances the piston 112to cause the material 170 to flow through and out of the nozzle 106 andinto the cavity. As material 170 fills the cavity, the physicianwithdraws the nozzle from the cavity and into the cannula instrument 30.The cannula instrument 30 channels the material 170 flow toward thecavity 168. As FIG. 28 shows, the cement material 170 flows in a streaminto the cavity 168.

[0162] If the selected material 170 is bone cement, the cement material170 is placed into the syringe chamber 110 shortly after it is mixedfrom two materials (e.g., in an external mixing device), while it is ina low viscosity, relatively free flowing liquid state, like a thinpancake batter. In time (e.g., about two minutes after mixing), theconsistency of the cement material 170 will change to a substantiallyputty-like character.

[0163] The physician operates the syringe 104 to expel the cementmaterial 170 from the chamber, through the nozzle 106, first into thecavity and then into the cannula instrument 30. Typically, at the end ofthe syringe injection process, material 170 should extend from thecavity and occupy about 40% to 50% of the cannula instrument 30.

[0164] When a desired volume of cement is expelled from the syringe 104,the physician withdraws the nozzle 106 from the cannula instrument 30,as FIG. 29 shows. The physician may first rotate the syringe 104 andnozzle 106, to break loose the material 170 in the nozzle 106 from theejected bolus of material 170 occupying the cannula instrument 30.

[0165] The physician acquires the tamping instrument 108 from the kit12. As FIG. 30 shows, the physician advances the tamping instrument 108through the cannula instrument 30. As phantom lines in FIG. 30 show, thehandle 60 can remain attached to the cannula instrument 30 to providestability, as the second passage 74 of the handle accommodates thetamping instrument 108.

[0166] The distal end of the tamping instrument 108 contacts theresidual volume of cement material 170 in the cannula instrument 30. AsFIGS. 30 and 31 show, advancement of the tamping instrument 108displaces progressively more of the residual material 170 from thecannula instrument 30, forcing it into the cavity 168. The flow ofmaterial 170 into the cavity 168, propelled by the advancement of thetamping instrument 108 in the cannula instrument 30, serves to uniformlydistribute and compact the material 170 inside the cavity 168, withoutthe application of undue pressure.

[0167] The use of the syringe 104, nozzle 106, and the tampinginstrument 108 allows the physician to exert precise control whenfilling the cavity with material 170. The physician can immediatelyadjust the volume and rate of delivery according to the particular localphysiological conditions encountered. The application of low pressure(i.e., no greater than 360 psi), which is uniformly applied by thesyringe 104 and the tamping instrument 108, allows the physician torespond to fill volume and flow resistance conditions in a virtuallyinstantaneous fashion. The chance of overfilling and leakage of material170 outside the cavity is significantly reduced.

[0168] When the physician is satisfied that the material 170 has beenamply distributed inside the cavity 168, the physician withdraws thetamping instrument 108 from the cannula instrument 30. The physicianpreferably first twists the tamping instrument 108 to cleanly breakcontact with the material 170. The handle 60 can now be removed and thecannula instrument 30 withdrawn, as FIG. 32 shows. The incision site issutured closed. The bone treatment procedure is concluded.

[0169] Eventually the material 170, if cement, will harden a rigid statewithin the cavity 168. The capability of the vertebral body 148 towithstand loads is thereby improved.

[0170] The selected material 170 can be an autograft or allograft bonegraft tissue collected in conventional ways. For example, the graftmaterial can be in paste form, as described by Dick, “Use of theAcetabular Reamer to Harvest Autogenic Bone Graft Material: A SimpleMethod for Producing Bone Paste,” Archives of Orthopaedic and TraumaticSurgery (1986), 105: 235-238, or in pellet form, as described by Bhan etal, “Percutaneous Bone Grafting for Nonunion and Delayed Union ofFractures of the Tibial Shaft,” International Orthopaedics (SICOT)(1993) 17: 310-312, both of which are incorporated herein by reference.Alternatively, the bone graft tissue can be obtained using a Bone GraftHarvester, which is commercially available from SpineTech. Using afunnel, the paste or pellet graft tissue material is loaded into thecannula instrument 30. The tamping instrument 108 is then advanced intothe cannula instrument 30 in the manner previously described, todisplace the paste or pellet graft tissue material out of the cannulainstrument 30 and into the cavity.

[0171] The selected material 170 can also comprise a granular bonematerial harvested from coral, e.g., ProOsteon™ calcium carbonategranules, available from Interpore. The granules are loaded into thecannula instrument 30 using a funnel and advanced into the cavity usingthe tamping instrument 108.

[0172] The selected material 170 can also comprise demineralized bonematrix suspended in glycerol (e.g., Grafton™ allograft materialavailable from Osteotech), or SRS™ calcium phosphate cement availablefrom Novian. These viscous materials, like the bone cement previouslydescribed, can be loaded into the syringe 104 and injected into thecavity using the nozzle 106, which is inserted through the cannulainstrument 30 into the cavity. The tamping instrument 108 is used todisplace residual material from the cannula instrument 30 into thecavity, as before described.

[0173] The selected material 170 can also be in sheet form, e.g.Collagraft™ material made from calcium carbonate powder and collagenfrom bovine bone. The sheet can be rolled into a tube and loaded by handinto the cannula instrument 30. The tamping instrument 108 is thenadvanced through the cannula instrument, to push and compact thematerial in the cavity.

[0174] VI. Alternative Embodiments

[0175] The use of low pressure delivery of material 170 frees the system10 from the need to accommodate relatively large diameter, high pressuredelivery devices. The interior diameter of the cannula instrument 30 canbe downsized accordingly, thereby minimizing the dimensions of thesubcutaneous pathway to gain access to the targeted bone region.

[0176] Typically, when low pressure material injection instruments areused, the largest tool that the reduced-diameter cannula instrument mustaccommodate is the expandable cavity-forming structure 82. The structure82 presents a minimal profile during deployment, as it can be collapsedand, if desired, a lubricous coating may also be applied to the exteriorof the structure 82 to facilitate its passage through thereduced-diameter cannula instrument.

[0177] A. Low Pressure Material Injection Instruments

[0178]FIG. 33 exemplifies low pressure material injection instruments180 and 182 that function in association with a cannula instrument 184having a reduced interior diameter, e.g. only about 3.4 mm or less.

[0179] One instrument 180 comprises a reduced-diameter nozzle. As FIG.33 shows, the nozzle 180 is sized to pass through the reduced-diametercannula instrument 184, to thereby pass into bone in the mannerpreviously shown in FIG. 26. The reduced-diameter nozzle 180 connects bya threaded connector 186 to the syringe 104. For material strength,despite its reduced dimension, the nozzle 180 is preferably formed froma rigid metal material, e.g., stainless steel.

[0180] As FIG. 33 shows, the reduced-diameter nozzle 180 also includesmeasured markings 188 along its length, as previously described. Themarkings 188 include a set point 190, as previously described, whichaligns with the proximal end of the cannula instrument 184 when thedistal ends of the cannula instrument 184 and the nozzle 180 align.

[0181] The other reduced diameter instrument 182 comprises a stylet,which is sized to pass through the interior bore of the nozzle 180. Thestylet 182 includes a handle 192, which rests on the proximal connector186 of the nozzle 180 when the stylet 182 is fully inserted into thenozzle 180. When the handle 192 is rested, the distal ends of the stylet182 and nozzle 180 align. The presence of the stylet 182 inside thenozzle 180 closes the interior nozzle bore.

[0182] In use, the nozzle 180 is coupled to the syringe 104 and insertedthrough the cannula instrument 184 into the material-receiving cavity168 formed in cancellous bone, in the same manner shown in FIG. 26.Material in the syringe 104 is injected at low pressure through thenozzle 180 into the cavity 168. As before explained, as the cavity 168progressively fills with material, the nozzle 180 is withdrawn back intothe cannula instrument 184. Typically, when the injection of material iscompleted, material extends from the cavity 168 and occupies about 40%to 50% of the cannula instrument 184.

[0183] At this point, the nozzle 180 can be fully withdrawn from thecannula instrument 184 and unthreaded from the syringe 104. The stylet182 can be advanced into the nozzle 180, to bring the handle 192 at restagainst the connector 186, thereby clearing residual material from thenozzle 180. The nozzle 180 and stylet can then be inserted as a nestedunit into the cannula instrument 184. Nested together, the nozzle 180and stylet 182 form a tamping instrument. Upon advancement through thecannula instrument 184, the nested nozzle 180 and stylet 182 displaceresidual material from the cannula instrument 184 into the cavity 168,in generally the same manner as previously shown in FIGS. 30 and 31,thereby uniformly compacting material within the cavity 168 in acontrolled fashion and without undue pressure.

[0184] Alternatively, a single-piece tamping instrument, separate fromthe nozzle 180, can be provided, downsized to fit through thereduced-diameter cannula instrument 184. In this embodiment, the stylet182 is not necessary, unless it is desired to reclaim material from thenozzle.

[0185] B. Cavity Forming Instrument

[0186]FIG. 34 shows a cavity forming instrument 194 intended to bedeployed through the reduced-diameter cannula instrument 184, shown inFIG. 33. In many respects, the instrument 194 is like the instrument 76,previously described and shown in FIG. 4A, and common reference numeralswill be assigned to common structural elements. The instrument 184includes a flexible catheter tube 78 having a proximal end 80 and adistal end 82. The proximal end 80 carries a handle grip 84, and thedistal end 82 carries an expandable structure 86, which, when deployedin bone, compacts cancellous bone and forms the cavity 168.

[0187] Unlike the previously-described instrument 76, the instrument 194carries an introducer sleeve 196. The introducer sleeve 196 slides alongthe catheter tube 78 between the handle grip 84 and the expandablestructure 86. The introducer sleeve 196 includes a tubular main body 198with a forward collar 200 and a rear collar 202.

[0188] The introducer sleeve 196 normally occupies an advanced positionon the instrument 194, as shown in FIG. 35. In this position, the mainbody 198 overlies and surrounds the expandable structure 86. The mainbody 198 is sized to compress the structure 86 to an outside diameterthat is slightly less than the interior diameter of the reduced-diametercannula instrument 184.

[0189] As FIG. 35 shows, when the introducer sleeve 196 occupies theadvanced position, the forward collar 200 extends beyond the distal endof the compressed expandable structure 82. As FIG. 36 shows, in thisposition, the forward collar 200 presents itself for engagement with theproximal end 204 of the cannula instrument 184. The forward collar 200is sized to have an interior diameter that makes friction-fit engagementabout the proximal end 204 of the cannula instrument 184.

[0190] As FIG. 36 shows, when it is time to deploy the expandablestructure 86 through the cannula instrument 184, the physician engagesthe forward collar 200 of the introducer sleeve 196 in a friction fitabout the proximal end 204 of the cannula instrument 184. As FIG. 37shows, advancing the catheter tube 78 moves the compressed structure 86through the main body 198 of the sleeve 196 and into the bore of thecannula instrument 184. The engagement of the forward collar 200 aboutthe proximal cannula end 204 aligns the axis of the structure 86 withthe axis of the cannula instrument 184, while compressing the structure86 to a diameter smaller than the interior of the cannula instrument184. Upon advancement of the catheter tube 78, the introducer sleeve 196guides the structure 86 into the cannula instrument 194 without tearingor other damage.

[0191] Once the expandable structure 86 is advanced through the cannulainstrument 184 and into bone, the physician can slide the introducersleeve 196 rearward away from the proximal cannula end 204, to break thefriction fit between the end 204 and the forward sleeve. As FIG. 34shows, the rear collar 202 of the sleeve 196 is sized to make a snap fitengagement about a stem 206, which surrounds the catheter tube 78 nearthe handle 84. The snap fit engagement stabilizes the position of thesleeve 196 during subsequent use and manipulation of the cavity-forminginstrument 194.

[0192] The features of the invention are set forth in the followingclaims.

We claim:
 1. An instrument for tamping material into bone through asubcutaneous path, the instrument comprising a body having a length anda terminus, and including markings located along the length atincrements from the terminus.
 2. An instrument according to claim 1wherein the body is made of a generally rigid material.
 3. An instrumentaccording to claim 1 wherein the length of the body is longer than thesubcutaneous path.
 4. An instrument according to claim 1 wherein thebody includes at least one radiopaque marker.
 5. A tamping instrumentcapable of advancement through a subcutaneous cannula having a distalend which leads into bone, the tamping instrument comprising a bodyhaving a terminus which, during the advancement, urges material residingin the cannula into bone, the body having markings to visually gauge theadvancement of the terminus through the subcutaneous cannula.
 6. Atamping instrument according to claim 5 wherein the body is made of agenerally rigid material.
 7. A tamping instrument according to claim 5wherein the length of the body is longer than the subcutaneous cannula.8. A tamping instrument according to claim 5 wherein the body includesat least one radiopaque marker.
 9. Apparatus for delivering materialinto bone comprising a cannula for establishing a subcutaneous path intobone, and a tamping instrument for advancement through the cannulacomprising a body having a terminus which, during the advancement, urgesmaterial residing in the cannula into bone.
 10. Apparatus according toclaim 9 wherein the body includes markings to visually gauge theadvancement of the terminus through the cannula.
 11. Apparatus accordingto claim 9 wherein the cannula has a length, and wherein the length ofthe tamping instrument exceeds the length of the cannula.
 12. Apparatusaccording to claim 11 wherein the body includes a set point markingspaced from the terminus at a distance generally equal to the length ofthe cannula.
 13. Apparatus according to claim 12 wherein the bodyincludes at least one additional marking to visually gauge advancementof the terminus through the cannula.
 14. Apparatus according to claim 9wherein the body includes at least one radiopaque marker.
 15. Apparatusaccording to claim 9 wherein the body is made of a generally rigidmaterial.
 16. Apparatus according to claim 9 and further including acavity forming instrument for advancement through the cannula into bonefor compressing cancellous bone.
 17. Apparatus according to claim 16wherein the cavity forming instrument includes an expandable structure.18. An assembly of items for delivering material into bone comprising acannula, a tamping instrument comprising a body having a terminus, andinstructions for using the kit according to a method comprising thesteps of deploying the cannula to establish a subcutaneous path intobone, introducing a material into bone through the cannula, andadvancing the terminus through the cannula to urge material residing inthe cannula into bone.
 19. An assembly according to claim 18 wherein thebody has a length and includes markings located along the length atincrements from the terminus to gauge advancement of the terminusthrough the cannula.
 20. An assembly according to claim 18 wherein thebody includes at least one radiopaque marker.
 21. An assembly accordingto claim 18 and further including a cavity forming instrument tocompress cancellous bone.
 22. An assembly according to claim 21 whereinthe cavity forming instrument includes an expandable structure.
 23. Anassembly according to claim 21 wherein the method further comprises thestep of deploying the cavity forming instrument through the cannula tocompress cancellous bone and form a cavity, and wherein the introducingand advancing steps introduces material into the cavity.
 24. Apparatusfor introducing material into bone through a subcutaneous cannula, theapparatus including a delivery device to convey the material at adelivery pressure of no greater than about 360 psi, and a nozzleinstrument capable of advancement through the subcutaneous cannula intobone and comprising a proximal fitting to couple the nozzle instrumentto the delivery device and a nozzle terminus through which the materialconveyed by the delivery device enters bone at the delivery pressure.25. Apparatus according to claim 24 wherein the nozzle instrument ismade of a generally flexible material.
 26. Apparatus according to claim24 wherein the nozzle instrument is made of a generally rigid material.27. Apparatus according to claim 24 wherein the delivery devicecomprises a syringe.
 28. Apparatus according to claim 24 and furtherincluding a tamping instrument capable of advancement through thesubcutaneous cannula and having a tamping terminus which, during theadvancement, urges material residing in the subcutaneous cannula intobone.
 29. Apparatus according to claim 28 wherein the tamping instrumentincludes markings to visually gauge the advancement of the tampingterminus through the subcutaneous cannula.
 30. Apparatus according toclaim 28 wherein the tamping instrument includes at least one radiopaquemarker.
 31. Apparatus according to claim 28 wherein the tampinginstrument is made of a generally rigid material.
 32. Apparatusaccording to claim 24 wherein the nozzle instrument includes markings tovisually gauge the advancement of the nozzle terminus through thesubcutaneous cannula.
 33. Apparatus according to claim 24 wherein thenozzle instrument includes at least one radiopaque marker.
 34. Apparatusaccording to claim 24 and further including a cavity forming instrumentcapable of advancement through the subcutaneous cannula to compresscancellous bone.
 35. Apparatus according to claim 34 wherein the cavityforming instrument includes an expandable structure.
 36. An assembly ofitems for introducing material into bone comprising a cannula, adelivery device having an actuator to convey material at a deliverypressure of no greater than about 360 psi, a nozzle instrument capableof advancement through the cannula into bone and comprising a proximalfitting to couple the nozzle instrument to the delivery device and anozzle terminus, and instructions for using the kit according to amethod comprising the steps of deploying the cannula to establish asubcutaneous path into bone, and actuating the delivery device to conveymaterial at the delivery pressure through the nozzle terminus into bone.37. An assembly according to claim 36 and further including a tampinginstrument capable of advancement through the cannula having a tampingterminus, and wherein the method further includes the step of advancingthe tamping terminus through the cannula to urge material residing inthe cannula into bone.
 38. An assembly according to claim 37 wherein thetamping instrument includes markings to visually gauge the advancementof the tamping terminus through the cannula.
 39. An assembly accordingto claim 37 wherein the tamping instrument includes at least oneradiopaque marker.
 40. An assembly according to claim 36 wherein thenozzle instrument includes markings to visually gauge the advancement ofthe nozzle terminus through the cannula.
 41. An assembly according toclaim 36 wherein the nozzle instrument includes at least one radiopaquemarker.
 42. An assembly according to claim 36 wherein the deliverydevice comprise a syringe.
 43. An assembly according to claim 36 andfurther including a cavity forming instrument to compress cancellousbone.
 44. An assembly according to claim 43 wherein the cavity forminginstrument includes an expandable structure.
 45. An assembly accordingto claim 43 wherein the method further comprises the step of deployingthe cavity forming instrument through the cannula to compress cancellousbone and form a cavity, and wherein the actuating step conveys materialinto the cavity.
 46. A tool for deployment into bone comprising acatheter tube having a distal region, an expandable structure carried bythe distal region for compacting cancellous bone, and an introducersleeve slidably carried by the catheter tube for movement between aretracted position spaced from the expandable structure and an advancedposition overlying the expandable structure, the introducer sleeveincluding a tubular main body dimensioned to compress the expandablestructure when the introducer sleeve is in the advanced position, and acollar extending beyond the distal region of the catheter tube when theintroducer sleeve is in the advanced position, the collar beingdimensioned larger than the tubular main body to releasably engage anend of a cannula, whereby the introducer sleeve both sizes and alignsthe expandable structure for passage into the cannula through the end ofthe cannula.
 47. A tool according to claim 46 wherein the catheter tubeincludes a proximal region having a stem, and wherein the introducersleeve includes a second collar extending from the main tubular bodyopposite to the first-defined collar, the second collar beingdimensioned to releasably engage the stem when the introducer sleeve isin the retracted position.
 48. A tool according to claim 47 wherein theproximal region includes a handle adjacent to the stem.
 49. A toolaccording to claim 46 wherein the catheter tube includes a proximalregion having a handle, and wherein the introducer sleeve includes asecond collar extending from the main tubular body opposite to thefirst-defined collar, the second collar being dimensioned to releasablyengage the handle when the introducer sleeve is in the retractedposition.
 50. Apparatus for introducing material into bone through asubcutaneous cannula, the apparatus including a delivery device toconvey the material at a delivery pressure of no greater than about 360psi, a nozzle instrument capable of advancement through the subcutaneouscannula into bone and comprising a proximal fitting to couple the nozzleinstrument to the delivery device and a nozzle bore through which thematerial conveyed by the delivery device enters bone at the deliverypressure, and a stylet capable of advancement into the nozzle borethrough the proximal fitting to close the nozzle bore and, with thenozzle instrument, forming a tamping instrument capable of advancementthrough the subcutaneous cannula to urge residual material from thesubcutaneous cannula.
 51. Apparatus according to claim 50 wherein thenozzle instrument includes markings to visually gauge the advancement ofthe nozzle instrument through the cannula.
 52. Apparatus according toclaim 50 wherein the delivery device comprises a syringe.
 53. A methodfor delivering material into bone comprising the steps of deploying acannula through soft tissue to establish a subcutaneous path into bone,introducing a material into bone through the cannula, and advancing atamping instrument through the cannula to urge material residing in thecannula into bone.
 54. A method according to claim 53 wherein theintroducing step delivers material at a pressure no greater than about360 psi.
 55. A method according to claim 53 wherein the introducing stepincludes using a manual syringe.
 56. A method according to claim 53wherein the material comprises bone cement.
 57. A method according toclaim 53 wherein the material comprises autograft tissue.
 58. A methodaccording to claim 53 wherein the material comprises allograft tissue.59. A method according to claim 53 wherein the material comprisessynthetic bone substitute.
 60. A method according to claim 53 whereinthe material comprises medication.
 61. A method according to claim 53wherein the material comprises a material that sets to a hardenedcondition.
 62. A method according to claim 53 and further including thestep of deploying a cavity forming instrument through the cannula tocompress cancellous bone and form a cavity, and wherein the introducingand advancing steps convey material into the cavity.